The Therapeutic Efficacy of Adjunct Therapeutic Plasma Exchange for Septic Shock with Multiple Organ Failure: A Single Center Retrospective Review

Abstract

Background: Sepsis remains a common condition with high mortality when multiple organ failure develops. The evidence for therapeutic plasma exchange (TPE) in this setting is promising but inconclusive. Our study aims to evaluate the efficacy of adjunct TPE for septic shock with multiple organ failure compared to standard therapy alone. Methods: A retrospective, observational chart review was performed, evaluating outcomes of patients with catecholamine resistant septic shock and multiple organ failure in Intensive Care Units at a tertiary care hospital in Winston Salem, North Carolina from August 2015- March 2019. Adult patients with catecholamine resistant septic shock (≥ 2 vasopressors) and evidence of multiple organ failure were included. Patients who received adjunct TPE were identified and compared to patients who received standard care alone. A propensity score using age, gender, chronic co-morbidities (HTN, DM, CKD, COPD), APACHE II score, SOFA score, lactate level, and number of vasopressors was used to match patients, resulting in 40 patients in each arm. Results: Mean baseline APACHE II and SOFA scores were 32.5 and 14.3 in TPE patients versus 32.7 and 13.8 in control patients. The 28-day mortality rate was 40% in the TPE group versus 65% in the standard care group (p=0.043). Improvements in baseline SOFA scores at 48 hours were greater in the TPE group compared to standard care alone (p=0.001), and patients receiving adjunct TPE had a more favorable fluid balance at 48 hours (p=0.01). Patients receiving adjunct TPE had longer ICU and hospital lengths of stay (p=0.003 and p=0.006). Conclusions: Our retrospective, observational study in adult patients with septic shock and multiple organ failure demonstrated improved 28-day survival with adjunct TPE compared to standard care alone. Hemodynamics, organ dysfunction, and fluid balance all improved with adjunct TPE, while lengths of stay were increased in survivors. The study design does not allow for a generalized statement of support for TPE in all cases of sepsis with multiple organ failure but offers valuable information for a prospective, randomized clinical trial.

The successful use of therapeutic plasma exchange for severe COVID-19 acute respiratory distress syndrome with multiple organ failure

“…Our group has developed institutional guidelines for TPE consideration in sepsis with multiple organ dysfunction syndrome (MODS) (from any pathogen), and recently completed a retrospective review of our single-center experience in this setting. 11 Details are available online, and a revised version of the article will be submitted for publication. In our study, nearly half the patients presented with pneumonia as the primary source of infection (39/80).…”

Coronavirus disease 2019: investigational therapies in the prevention and treatment of hyperinflammation

“…Prior experience in patients with acute lung injury due to the 2009 pH1N1 influenza A virus showed improvement in hemodynamic status and PaO2/FiO2 ratio after TPE [185]. Another retrospective observational study showed improvement in adjunctive use of TPE in patients with septic shock due to pneumonia [186]. Due to the limited evidence, TPE should be further investigated regarding a possible role in treatment of COVID-19-CSS, ideally in randomized clinical trials.…”

The use of therapeutic plasma exchange as adjunctive therapy in the treatment of coronavirus disease 2019: A critical appraisal of the current evidence

“…An unpublished retrospective observational study comparing 40 patients with COVID‐19 complicated by MOF and septic shock who received adjunct TPE with 40 propensity matched controls who received supportive care without TPE found no difference in PaO2/FiO2 (P/F) ratio between the two groups at 48 h after TPE ( P = .84). After subgroup analysis, the 28‐day mortality benefit (47.8% vs 81.3%; P = .05) may be present for patients with pneumonia as the primary source of sepsis treated with TPE 47 …”

“…Therapeutic plasma exchange has additionally been used to treat severe COVID‐19 with ARDS accompanied by MOF and/or septic shock 23,43‐47 . Keith et al 43 reported a single patient experience with COVID‐19 positive pneumonia who developed MOF and septic shock requiring cardioversion and mechanical ventilation.…”